COVER STORY
Courage,
relationships,
and applicability
Big research from small places
Story by Sarah de Leeuw
D
r Martin Fortin remembers feeling the chances of success were pretty slim on his frst major research grant application.“I was writing that grant on September 11, 2001,” recalls Dr Fortin. “I said to myself, well, there might not be any funding for anything after today because we might all be at war.”
Still, Martin Fortin continued to work on the application. Writing a research grant in the face of potential world war, continuing against the odds in the name of expanding a feld of research—well, let’s just say courage and perseverance are in Dr Fortin’s DNA.
“I come from a very modest family. I am the 21st child. The last child. There were 9 kids with my father’s frst wife, 12 with my mother. We were not a family of doctors. We were rich for the numbers of us, for the support we could give each other, not for money. While we did manage well, when I started medicine, I had to pay for everything. My parents could not afford to help me with anything. There were no second chances, you know. I always knew I wanted to come back and work in small places. That requires a kind of courage.”
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de septembre 2017 à la page e400.
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Dr Fortin’s promise to himself about returning to work in rural or small urban communities has been fully kept. He is now Professor with the Department of Family Medicine and Emergency Medicine in the Faculty of Medicine and Health Sciences at the University of Sherbrooke. He is also a family doctor with the Groupe de médecine de famille universitaire de Chicoutimi and Directeur de la recherche with the Centre intégré uni- versitaire de santé et de services sociaux du Saguenay–
Lac-St-Jean.1,2
Both Sherbrooke and Saguenay are not far away from the small communities, full of outdoor activities and close-to-nature living, that Fortin recalls from his youth:
they are places that might have inspired the early cre- ativity and curiosity now borne out in an ever expanding passion about research by and for family practitioners.
“I remember one feeling I had. I was in my offce in the early 2000s. I was with a patient who had 9 or 10 medications and they would always be coming to me for new problems requiring prescriptions. I suddenly found myself thinking ‘Is this a good thing?’ Yes, I could check for interactions between the medications, but I saw a larger ethical dilemma: ‘Is this a good thing, overall, for the patient?’ That was the frst spark of the fame. I real- ized reasons for our decisions in family medicine must be grounded in evidence and data produced by us, rep- resenting what we in our discipline are doing. The cre- ation of evidence from specialized care fields comes from very specifc populations, through randomized tri- als. Can this be generalized? Our patients in primary care are often much sicker than the people in those tri- als, in that research.”
Those questions are the backbone of Dr Fortin’s research agenda. They informed that frst grant appli- cation he wrote, shortly after that spark lit into a fame following a brainstorming session with colleagues and the researcher he credits as a mentor. “I was still work- ing with a small number of residents. I didn’t really have a research agenda. But a group of us decided to have a brainstorming session. We were asking, what was important to family medicine? What are the topics that should defne our research agenda? And I just submit- ted this idea: maybe we need to explore what is going on with patients who have multiple chronic diseases. A colleague said ‘now that’s a good idea’ and I was excited about having a topic supported.”
Dr Fortin continues to work closely with the col- league and “mentor” who supported his idea all those years ago: his relationship with Dr Moira Stewart, a researcher on patient-centred care at Western University in London, Ont, is foundational to his overall orientation to research.3
“Mentorship is crucial. Learning from patients is cru- cial. We now have a group of 12 to 14 patients who we meet with on a monthly basis and we talk about all types of various topics. It’s fabulous, that chance to meet with patients, to learn from them about clinical care. They have so much to give me as a researcher: what they are feeling, what are they experiencing. They have changed our thinking as researchers on so many things.”
Applicability to practice and patients, mentorship, and relationships: these, according to Fortin, are the most important and key elements of research meaningful to primary care physicians.
WHAT IS GOING ON WITH PATIENTS WHO HAVE MULTIPLE
CHRONIC DISEASES?
PHOTO (Above) The Little White House (la Petite Maison Blanche) was the only building that was not destroyed in this neighbourhood after the 1996 flood in Saguenay, Que. The neighbourhood was never rebuilt but was replaced by a city park around the Little White House, which is now a museum. (Opposite) L Église Sacré-Coeur.
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“The development of a team, of relationships with staff. Those have always been so important to me. I’m a little shy. It’s that part of my background. A youngest child. And I’m kind of a family guy. I like to reproduce a family feeling in the research I do. I have a family in practice and I have a family in research. It is so impor- tant to have relationships. I think you also have to have fun. I like it when everybody is laughing in research team meetings. There has to be humour. If a person isn’t the kind of person you could sit and have a beer with, you probably can’t have a research relationship with them. The family dimension in ‘family’ practice research. It’s so important.”
What is also important, according to Fortin, is that research always be directly relevant to patients and practice. He admits that, in addition to fun and a com- mitment to relationships, some of his passion for
research arises out of annoyance. “I am still worried the evidence for my patients is not correct. I’m asked to apply guidelines, but where do those guidelines come from? I have discovered some of my research questions from accumulating frustrations. We are our patients’ advocates. We have to create our own evi- dence. We have to be motivated to create our own evidence.”
The motivation to create evidence by and for family practitioners is, in part because of Dr Martin Fortin’s research agenda, growing. “Ten years ago, I would have said that residents really didn’t like research. But that is changing. Why? I don’t fully know. I do think it is our mentorship, our teaching. I am more and more taken aback with the heart residents put into prepar- ing their research. They are sharing too. It is informing their practice.”
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The youngest of 21 children surely knows a thing or two about change across generations. Now a father of 5 himself, Dr Martin Fortin continues to believe that the concept of “family” is at the heart of research about family practice. “As family doctors, we are closer to the human being, to the patient being human. We are closer to their families, to their environments. We work in a different paradigm. We can ask about what makes them over- whelmed, what they need. We are their long-term rela- tionships. That is our research.”
Dr Fortin is a family doctor in Saguenay, Que, and Professor in the Department of Family Medicine and Emergency Medicine in the Faculty of Medicine and Health Sciences at the University of Sherbrooke in Quebec. He is among the world leaders in research on the topic of multimorbidity in primary care.
The Cover Project The Faces of Family Medicine project has evolved from individual faces of family medicine in Canada to portraits of physicians and communities across the country grappling with some of the inequities and challenges pervading society. It is our hope that over time this collection of covers and stories will help us to enhance our relationships with our patients in our own communities.
References
1. Fortin M, Chouinard MC, Dubois MF, Bélanger M, Almirall J, Bouhali T, et al.
Integration of chronic disease prevention and management services into pri- mary care: a pragmatic randomized controlled trial (PR1MaC). CMAJ Open 2016;4(4):E588-98.
2. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimor- bidity among adults seen in family practice. Ann Fam Med 2005;3(3):223-8.
3. Fortin M, Stewart M, Poitras ME, Almirall J, Maddocks H. A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology.
Ann Fam Med 2012;10(2):142-51.
PHOTOS TOP (Left) Dr Moira Stewart and Dr Martin Fortin meet on a regular basis for the team funded by Canadian Institutes of Health Research that they lead:
Patient-Centred Innovations for Persons with Multimorbidity. (Centre) Dr Fortin in a working session with his research staff: (clockwise from top left) José Almirall, André Côté, Andrée-Ann Dufour, Tarek Bouhali, and Bayero Boubacar Diallo.
(Right) On the balcony overlooking the Saguenay River: (left to right) Tarek Bouhali, Diane Cormier,* Carol Jomphe,* André Côté, Andrée-Ann Dufour, José Almirall, Martin Fortin, Paul Racine,* Bayero Boubacar Diallo, and Marcel Lachance.*
BOTTOM PHOTO Near the pond situated at the Zone Portuaire in Saguenay, Dr Fortin refects on his day.
*Patients engaged in research with Dr Fortin’s team.
PHOTOGRAPHER Andrée Lanthier, Longueuil, Que
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